Anesthesia strategies to minimize lung atelectasis in peripheral bronchoscopy

Peripheral bronchoscopy has become a widely adopted, minimally invasive modality for the diagnosis of peripheral lung lesions. However, its diagnostic yield remains limited in part due to intra-procedural atelectasis - a frequently overlooked phenomenon that obscures lesions and exacerbates computed tomography (CT)-to-body divergence. This review highlights the prevalence and clinical impact of atelectasis during navigational bronchoscopy and presents anesthesia and ventilation strategies to mitigate its occurrence.

Emerging data from trials such as I-LOCATE, ventilatory strategy to prevent atelectasis (VESPA), and lung navigation ventilation protocol (LNVP) studies show that atelectasis develops early and frequently during bronchoscopy, particularly in dependent lung zones and patients with high BMI. Strategies to reduce atelectasis include high tidal volumes, optimized positive end-expiratory pressure, reduced FiO 2 , and recruitment maneuvers. Dedicated ventilation protocols like VESPA and LNVP have significantly reduced both incidence and severity of atelectasis, improved lesion visibility, and demonstrated safety. Apneic breath-hold techniques further enhance image quality and lesion targeting.

Atelectasis is a modifiable barrier to diagnostic success in peripheral bronchoscopy. Proactive pre and intra-procedural planning, implementation of structured ventilation protocols, and close collaboration with anesthesia are essential. Future research should focus on protocol standardization, novel imaging synchronization techniques, and validation of atelectasis grading tools.